If you didn’t know it left or that someone stole it, I’ll give you a pass. Medicine has been disguised for a long time now. And, when you leave the scene in camouflage, you often go unnoticed.

Medicine is supposed to be the science or practice of diagnosing, treating, and preventing disease. I love medicine. There’s so much to learn. Lots of complexities and so many people to help. Medicine gives me an avenue to serve, because if we don’t have our health, what do we have? Illness. And, none of us want that.

I’ve trained to be a physician. I’ve learned lots of things that can help you with sickness. But, in order to do this, THEY have to let me practice. And, yes, THEY are the people who have taken Medicine.

When did medicine become more about meeting than doing? When I first became interested in medicine, physicians worked. We worked days and nights, hours on end. We learned by working. We worked by doing. And, things weren’t perfect then. But, we took care of patients by actually doing something that literally moved the needle.

Now, it’s different. We just meet about it.

Toward the end of my medical training, administrative meetings were already running rampant. We’d meet because some group said we should be doing a quality improvement project. Just some new regulatory thing. Gotta come up with a project. Every year.

News flash for the folks scheduling meetings: that’s not how innovation works.

Bureaucracies don’t drive innovation. Never have. Never will. I’ll tell you how we did those practice improvement projects that someone else told us we should be doing. We usually would type up some protocol that we were already doing and then add it as another formal policy. Box checked. That’s what humans do when they are given futile tasks with poor incentives.

Meetings in healthcare have really just become smokescreens for governement-driven busywork. Sure, they can be functional, and in fact, they always add more functions for all of us to be doing. But, most of the time these meetings aren’t productive for patient care because they’ve lost sight of the one thing medicine was built upon: the patient-physician relationship.

Take a look at the graph included here. It outlines the growth of administrators in healthcare compared to physicians over the last forty years. And, it includes an overlay of America’s healthcare spending over that same time. Take a look at the yellow color. A picture is worth a thousand words, isn’t it?

You see, when you have that much administration, what you really have is a bunch of meetings. Lots of folks carrying their coffee from place to place. They are meeting about more policies, more protocols to satisfy government-created nonsense. But, this type of thing in healthcare isn’t fixing things. It’s not moving the needle.

What moves things is innovation. And, innovation isn’t some concept that responds to being forced. It develops when the right chemicals exist in the right moment for an exciting explosion. It happens when someone in a free-market recognizes a problem and creates a business idea to solve it. But, we’ve completely lost this environment for innovation in healthcare. Medicine has been kidnapped by a bunch of government-driven regulations that cost billions of unnecessary tax-payer dollars for oversight.

I get it. We need some administrators. And, I’ve got a few good friends that do this job well. THEY should be somewhere on the graph, because medical providers need support systems. I get their role. I’ve got a Master’s Degree in health organizational management myself.

But, the point I’m making is that the bureaucracy has exploded out of control. When you have so many excessive regulations that you need that many people overseeing checkboxes instead of delivering medical care, you aren’t just stifling innovation, you are having untoward effects on cost control. Medicine used to be about you and me. In fact, where in the world did the patient-physician relationship go? I guess that it left when Medicine did.

I don’t care what you do. You can take me out, join me, or get out of my way. But, I’m on a mission to take medicine back.

*****

Note: These additional comments are being provided for those more interested in absolute numbers (and not percentages) related to the figure above. According to “Practical Solutions for Healthcare Management and Policy” (Trusko, Pexton, Gupta, et. al), in 2010, the Bureau of Labor Statistics noted that “4.5 million” Americans were employed in healthcare management and administrative support. The reference goes on to outline that this 4.5 million people DOES NOT include (1) the ranks of workers being used to setup and manage health information technology systems, (2) the more than 926,000 additional people in the U.S. working for life and health insurance companies, (3) the more than 724,000 employees of insurance brokers and consulting firms, (4) the tens of thousands of others working in corporate health benefits departments, and (5) those employed at the corporate headquarters of hundreds of supporting companies. In contrast, in 2010, there were only about 820,000 clinically active U.S. physicians.

There is much frustration with the practice of medicine, and many physicians write about it. But what are we going to do, and how should it be focused?

You already know doctors will NOT be the leaders in this problem as they are too busy trying to survive. There are probably a hundred physician blogs around the country…many stating exactly what you have said. But organizing medical professionals has been futile.

The public has been propagandized by big business and government the direction American medicine should go. Their motivation has been profit as lawmakers fill their coffers with donation to the detriment of our patients.

For several years I have suggested physician writers like yourself organize into a group bringing to the public clarity of the ongoing business takeover of medicine. Leadership though is lacking, ideas dead-ended, and motivation stonewalled.

Finding those who see the problems and can distinctly write about them is our challenge.

When the American people remain ignorant of the problems, we will all suffer.

There is an upcoming Summit July 20-26 in Keystone that can be attended in person or via webcast. The webcast has no cost, only an ask for donation to help with technical costs. I’m not saying it’s what you are hoping for… I’m just saying that I’m hopeful.

In addition, I personally have joined Doc Squad, which was started in late 2011 with the idea that we could identify, train, organize and deploy physicians on the front lines of the debate on public policy with an eye towards electing more officials who share our beliefs — supremacy of the doc patient relationship, less or no third party payers, etc. Doc Squad received a grant in 2014 and the organization has been able to get over 150 publications and over 200 media opportunities for its docs. Doc Squad has also started a SUPER PAC. Again, time will tell.

“The secret of getting ahead is getting started.” –Mark Twain

Kind regards,
RB

docforfreedom

I am being chased by hospital bureaucrats to register as a “non-billing Medicaid provider” on penalty of being removed from the medical staff. Apparently the ACA insists that I get a number or the hospital will not get paid for services rendered. I have a license, a CDS number, a DEA number, and NPI number– so what more do they need to prove I am qualified to order tests and treatments? I am not enrolled in Medicaid but prefer to see these patients in our non-government free clinic. I do not admit Medicaid patients to the hospital. But now I must sign up for a program I have no intention of billing? Who thinks this stuff up? It is bureaucracy out of control.

RocK8Doc

“The introduction of various regulatory processes has resulted in a cancerous growth in the numbers of medical administrators at all levels of incompetence.”

This slippery slope was presciently predicted by Milton Friedman quoting a Swedish physician in 1978 @ Mayo ” How to be a clinician in a socialistic country:

It is obvious the existence of competing free market constitutes continued threat to the operation of socialist public service however heavily subsidized by taxpayers money. The element of quality that arises from patient’s personal preference and confidence in certain doctors cannot be easily done away with so long as the people are willing to pay for a free choice of physicians.

To do away with such opportunities therefore has become a new goal of~ ~ health care politicians.

charlie Mcadams

I have a number of wonderful doctors who have fixed me, got me back on track and who have done a lot more than talk and meet. You just need to get better doctors. Admin people free up physicians to help more.

Admin people do not free up doctors!!!! Your doctors are taking extra time (unpaid time) to take care of you and to listen. They are taking time away from their family, personal pursuits, hobbies and sleep. Right after they take the time with you the admin person walks up with a stack of paperwork to check off and then sends them to websites to learn how to “listen and respond” to our patients. If we did not come with those skills to medical school we will not have them in our practice. You are very fortunate to have your doctors. Most of us are still trying to have a human relationship with our patients but it will go.

pete pisula

The chart is way off. If administrative and clerical staff had increased 3200% since 1970, that would equate, in raw numbers, of a jump from less than 150,000 administrators to 4,500,000.

You made me smile because you reminded me about a college roommate that I once had who I referred to as a “science skeptic.” Tongue-in-cheek aside, I actually enjoy the skepticism because it can further help to chase down facts.

The reference for the chart is found at the bottom of the image. There is a second, unrelated, reference given at the conclusion of the post that goes into additional details about raw numbers which supports the original chart and its reference. (I assume that you saw that paragraph at the conclusion of the post, but I just wanted to make sure.)

Based upon the citations mentioned, which involve the U.S. Bureau of Labor and Statistics, a minimum of 4.5 million people were involved in healthcare administration in 2010, and depending on your definition of “administrator,” this figure may really have been as high as 7 million.

Regardless, if you started with 150,000 administrators in 1970, with a 3200% increase, this would give you between 4.5 to 5 million administrators in 2010, a figure inline with the numbers outlined above. For comparison, approximately 300,000 practicing physicians existed in 1970 (https://www.citizen.org/documents/DrSupplyFactSheet_Final.pdf).

Bringing all this together, in 1970, there would have been a ratio of 1 administrator for every 2 physicians. By 2010, this ratio appears to have morphed into at least 10-12 administrators for the same 2 physicians.

If all this math is starting to give you a headache (like it is me), you may just prefer to observe work getting done at the hospital nearest you. And, if your hospital is anything like what I’ve worked at in recent years, by the end of your observation day, you’ll be seeing more yellow (like the chart) than you could have ever imagined.

The bureaucracy is definitely alive. Just not sure how “well” it’s doing.

The book reference actually goes into all those details about how things are defined so that apples get compared to apples, and so on. Google Books lets you read many of the pages, which you may want to do, before coming to too many conclusions.

I’m just perplexed regarding your ongoing assumption that the percentages are “exaggerated.” The percentages are not exaggerated based upon the numbers that are provided. In fact, the graph (see the reference at the bottom of the image) is actually taken from the same authors (Himmelstein and Woolhandler) that provided the data in the 1996 article that I just had you review. Yes, the graph is from the same folks that referenced the 129,000 “managers and related” in 1968. It’s just these authors’ updated 2009 figures.

Now, I suppose you could argue that these authors’ data is inaccurate, but I don’t see your point that the image (which is based upon their data) has exaggerated the percentages.

This is pure, unadulterated clickbait. The primary source for chart this seems to a study by Himmelstein/Woolhandler that was published in 1996 – using “data from a census survey and outpatient employment from 1968 to 1993.” The KFF line looks to have been added as an overlay for what looks to be NHE.

No links were provided and the text referenced in the footnotes is $135 (1 lone 3-star review) on Amazon.

As Pete Pisula suggests – the chart seems to support the idea that admin staff grew some 3,200% – which equates to a growth from 150,000 to 4.5M (1970 to 2010). Similarly – in the timeframe quoted, the number of providers grew from 334,028 to 985,375 – which is almost 200%. As is – the chart does not reflect anything close to 200% for the provider growth over that period of time.

We absolutely do have administrative challenges in healthcare – but they are not reflected in this chart – and the provocative nature of the way this data is presented only serves to exacerbate the enormous (and growing) friction between payers and providers. Like all Holy Wars – this one’s over money – lots of it – and civilians (patients) are simply the collateral damage.

And, the findings on this graph can be interpreted a number of ways. This data is commonly referenced by a number of large organizations, including Physicians for a National Health Program (PNHP). I don’t agree with PNHP’s solutions, but you can see PNHP’s own chart outlining this information and a link to their website from the article here:

I’m just not sure why you state “the chart does not reflect anything close to 200% for the provider growth over that period of time.” The chart DOES reflect between a 125% to 250% provider growth over the years included. See zoomed image below.

Commonly referenced doesn’t equal a publicly verifiable source – it just means the same chart is appearing elsewhere – and the result is counterproductive to a healthy, constructive dialog.

Simply naming BL and NCHS isn’t a reference – it’s a complete dodge – and only serves to exacerbate the enormous friction between providers (like yourself) and payers (who patients MUST rely on to pay for astronomical provider bills). Zoom as much as you like – I’m still not convinced that’s close to an approximation for 200% and I suspect, the more you zoom in – the lower the final # would be.

The 1996 H/W study uses data from 1968 to 1993 – and yet the chart blindly carries forward to 2010? Somehow we’re supposed to blindly accept the fact that in 1970 there were only 150,000 “administrators” for all of U.S. healthcare but that in 2010 there are now 4.5 million? What is the definition of an “administrator” and according to who?

All of which goes to the heart of this issue – credibility. Anyone, of course, is free to foster and promote provocative charts and recreations of data they can bake in Excel to support their POV – but then they shouldn’t be surprised at the lack of credibility that results.

If and when you would like to talk about data that’s relevant and critical to the consumer/patient cost of healthcare (like the Milliman Medical Index below), please – do engage directly. FYI – Milliman is an actuarial firm with a history going back almost 75 years. The index they calculate (which I chart going back to 2002) is directly accessible – along with the full report (for all to see/verify) here: http://www.milliman.com/mmi/

I actually respect your intent to discredit “fuzzy math” because it frequently abounds in science and medicine.

This chart, however, is not “fuzzy” math. It says what it does. And, raw numbers suggest that in 1970, there was about 1 administrator for every 2 physicians. By 2010, this ratio had morphed into at least 10-12 administrators for the same 2 physicians.

I haven’t dodged anything. I’ve outlined many sources in my original posts and my comments section. And, Himmelstein’s data does not end in 1993. You can review a more recent authored article by Himmelstein here:

You can also contact Himmelstein directly via email (which can be found on the left side of the webpage listed above) if you have questions with Himmelstein’s validity on this matter.

Much of my blog (not just this one post) really does seek to point out what may be “relevant and critical to the consumer/patient cost of healthcare.” You will have a hard time challenging my own intent, but I’ll be the first to tell you that I do not have all the answers.

I just don’t want you to assume that this chart is trying to prove some “cause” of all healthcare costs. As I’m sure you know well, causation and correlation aren’t necessarily related.

The graph really just shows a “correlation” between two indisputable facts: (1) growth of U.S. healthcare administration and (2) increasing U.S. healthcare costs. Many possible “causes” for this correlation are discussed throughout my blog and in my own book: Finding Truth in Transparency (http://bilhartzmd.com/?page_id=19).

If your intent is to have us believe this data, I would encourage you to provide ALL relevant links and supporting studies/quotes in the original post – including any evidence/commentary from Himmelstein directly.

True – but what you have to be careful of with that is the old adage that you never get a second chance to make a first impression.

I agree that we have many challenges – some of which revolve around our system of selective health coverage – but I’m still not convinced of the validity of the data – or the chart – or (ultimately) it’s value in productive dialog/debate.

stan whitney

Hey Dan, I don’t know what your background and exposure to medicine is but I have worked in healthcare for over 25 years around both sides of the fence and I agree that there is an issue regarding money. The current goal of the government is to push providers out of individual practice and into large (hospital) organizations. This is for a number of reasons but includes the fact that Obamacare was crafted mainly by insurance providers and hospitals with the goal of using the control of the hospitals to control providers. The “savings” that the hospitals could extract from the providers would be used to expand care and “lower” costs. This has amounted to pushing patients from small efficient outpatient care into the hospital system with all the massive costs associated with this. Unfortunately, Dr. Bilhartz is correct, although the data may be subject to debate, about the huge administrative bloat in medicine today. The source of this bloat runs from the hospital administrative staff to the massive Washington bureaucracy that is involved. I have seen first hand the backside of the costs involved from the community level to Washington. There is no magic bullet to solve things but I have little faith in the current plans to help and as more data comes in, it is becoming apparent that the current plan will only make things worse.

I do agree that (through the years) primary care has been sacrificed at the expense of specialties – but that’s an internal dynamic to providers. In many ways – providers can thank the AMA for their complicit hand in this chart (see below).

Primary care is the lowest paid of all – but the debt to get there is on par with many others. We load up docs with student debt – take away 10 years (at least) of earning power – and then expect them to choose primary care? Right. Not going to happen – and it’s unreasonable to expect that it could.

I agree that the things you mention were needed. The current plan is not practical and also will fail to control costs in a way that is acceptable to Americans. I wish I had a overall plan for dealing with it but I do not believe anyone does, including the current plan, which gives Washington administrators almost complete unaccountable control over spending. The way access is currently being expanded is though the dumbing down of medicine. I don’t want to be impolite but, MD’s are using extenders (nurses, PAs, etc.) to make ends meet. I have refused to do this since starting practice because they (extenders) do not have the skills to deal with many of the complicated patient problems that I encounter daily. They also lack the depth of training to manage on the fly things that only someone with an MD/DOs training have to deal with. If they went to medical school/residency, they would have those skills. Extenders can be helpful but many times increase the cost of healthcare just because of lack of training….adverse events, excess/wrong tests, missed diagnosis, over/under-medication, etc.,etc. Expecting anyone who doesn’t have insight into these things…like an economist, accountant, insurance agent, lawyer, government administrator, whatever…is unrealistic.